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The Process of Counseling and Therapy

Summary

Taking a verypractical"how to be a psychotherapist" approach, this overview of the process of counseling provides information that isfundamentalto counseling, butnotrepresentative of any one theoretical orientation. Concise, yet thorough--and accessible to novice and seasoned professional alike--it explores counseling basics (e.g., skills, relationship building) as well as specific populations (e.g., groups, clients in crisis, couples and diverse populations).Foundation skills. The initial interview. The early phase. The middle phase. The final phase. The client in crisis. Groups and group therapy. Couple therapy. Dealing with diversity. Care and feeding of therapists.For new and seasoned professionals in counsel and psychotherapy.

Table of Contents

Preface

xi

First Things First

1

(12)

Therapy Then and Now

3

(2)

The Therapy Depot

5

(1)

Evaluating Outcomes

6

(3)

Theory, Assumptions, Values

9

(4)

Foundation Skills

13

(24)

Listening

15

(7)

Minimal Encouragers

16

(1)

Paraphrasing

16

(3)

Perception Checks

19

(1)

Summaries

20

(1)

I-Statements

21

(1)

Problem Solving

22

(8)

Goal Setting

22

(3)

Using Questions

25

(2)

Feedback

27

(2)

Advice

29

(1)

Dealing with Feelings

30

(7)

Timing

33

(1)

Therapist Feelings

34

(1)

Sharing Your Feelings

35

(2)

The Initial Interview

37

(20)

Preparation

38

(1)

Getting Started

39

(4)

Centering

40

(1)

Following the Client's Lead

41

(1)

Being Yourself

42

(1)

Gathering Information

43

(5)

Diagnosis and Assessment

46

(2)

Answers

48

(6)

Will You Continue?

49

(2)

How Will You Work Together?

51

(2)

How Often, How Long, How Much?

53

(1)

Ending the Session

54

(3)

The Early Phase

57

(18)

Rapport

58

(3)

The Therapist As Teacher

61

(5)

How to Talk

61

(2)

A Common Vocabulary

63

(1)

Skill Building

64

(1)

How To Be a Client

65

(1)

Contracting for Change

66

(6)

What Is a Therapeutic Contract?

66

(1)

Phases of the Contracting Process

67

(1)

The SAFE Contract

68

(2)

Building a Contract

70

(1)

A Few Last Words about Contracts

71

(1)

Limits

72

(2)

Conclusions

74

(1)

The Middle Phase

75

(24)

The Relationship As a Change Agent

77

(2)

Emotional Work

79

(7)

Emotion and Discomfort

81

(2)

Permission and Protection

83

(2)

To Touch or Not to Touch

85

(1)

Plunging into the Process

86

(8)

Agreement and Disagreement

87

(1)

Silence

88

(2)

Resistance

90

(3)

Getting Unstuck

93

(1)

Timing

94

(3)

Closing a Session

96

(1)

Middle-Phase Retrospective

97

(2)

The Final Phase

99

(23)

Planning for Termination

100

(6)

When to Terminate

102

(4)

The Work of the Final Phase

106

(3)

Repeating Old Themes

107

(1)

Hanging On

107

(2)

Feeling Reactions to Termination

109

(5)

Sadness

109

(1)

Anger

110

(1)

Fear

111

(1)

Guilt

112

(1)

Pleasant Affect

113

(1)

Therapist Feelings

114

(2)

Unplanned Terminations

116

(4)

The ``No-Show''

116

(2)

The ``Abrupt Stopper''

118

(2)

Therapist-Initiated Terminations

120

(1)

And, to Terminate This Chapter ...

120

(2)

The Client in Crisis

122

(26)

Basic Principles

123

(3)

First Steps with a Client in Crisis

126

(11)

Gathering Information

126

(1)

Resources

127

(1)

Confidentiality

128

(1)

The Crisis Contract

129

(1)

Moving In

130

(1)

Cognitive Work

131

(2)

Affective Work

133

(2)

Some Guidelines

135

(2)

Suicide

137

(9)

Recognizing the Suicidal Client

138

(1)

Assessment of Suicide Danger

139

(2)

The Meaning of Suicide

141

(2)

What to Do

143

(3)

Conclusions

146

(2)

Groups and Group Therapy

148

(23)

Curative Elements of the Group

148

(7)

Imparting Information

149

(1)

Socializing Techniques

150

(1)

Instilling Hope

150

(1)

Universality

151

(1)

Altruism

151

(1)

Cohesiveness

152

(1)

Transference

153

(1)

Imitation

154

(1)

Catharsis

154

(1)

Building and Maintaining the Group

155

(5)

Initial Information

155

(3)

Setting the Stage

158

(2)

Therapeutic Guidelines

160

(5)

Noticing Process

161

(1)

Interventions

162

(1)

Confrontations

163

(2)

Problems

165

(4)

Air Time

165

(1)

Monopolizing

166

(1)

Rescuers and Victims

167

(1)

Disrupting and Scapegoating

168

(1)

A Few Last Thoughts

169

(2)

Couple Therapy

171

(23)

The First Steps

172

(4)

Assessment and History Taking

174

(1)

Treatment Planning

175

(1)

The Art of Couple Therapy

176

(4)

General Guidelines

176

(4)

Problem Solving

180

(3)

Identifying the Problem

180

(2)

Finding Antecedents

182

(1)

Vulnerability

183

(1)

Common Patterns

183

(4)

Blaming and Complaining

184

(1)

Hurting Each Other

185

(1)

Double Binding

185

(1)

Fusion

186

(1)

Responsibility

187

(1)

Some Special Situations

187

(6)

Sexual Dysfunction

187

(1)

Gay and Lesbian Couples

188

(2)

The Extramarital Affair

190

(2)

Separation Therapy

192

(1)

A Final Word

193

(1)

Dealing with Diversity

194

(20)

Therapist Assumptions

196

(1)

Client Needs

197

(1)

General Guidelines

198

(7)

Explaining Your Role

201

(1)

Referral

202

(1)

Getting Started

203

(2)

Specific Cultural Groups

205

(7)

African Americans

205

(1)

Hispanics

206

(1)

Asians

207

(1)

Gay and Lesbian Clients

208

(2)

The Elderly

210

(1)

Religion

211

(1)

In Conclusion

212

(2)

Care and Feeding of Therapists

214

(24)

Professionalism

215

(6)

The Setting

216

(2)

The Exchange

218

(2)

The Attitude of a Professional

220

(1)

Legal and Ethical Issues

221

(10)

Responsibilities to the Client

224

(2)

Confidentiality

226

(4)

Extra-Therapeutic Relationships

230

(1)

Therapist Self-Care

231

(7)

Physical Well-Being

231

(1)

Emotional Well-Being

232

(2)

Special Concerns

234

(2)

Growth and Development

236

(2)

References

238

(9)

Index

247

Excerpts

Nine years later, and time for another edition. The first question a reader/student may well ask is "why?" Is it just to make all those used copies obsolete, so as to make more money selling new ones? (That''s what I firmly believed when I was a student.) Or, do the authors get more glory--and better chance of promotion--by churning out new editions of their books? Well, dear readers, I''m glad to be able to tell you that neither of these answers is correct. The real reason for putting out a new edition is&3151;it''s needed. A lot has happened in seven years; lots of research has been done, new aspects of therapy have been discovered or rediscovered, the social climate in which therapy and counseling take place has changed enormously. I''m also glad to be able to say that the basic premises upon which this book was originally written, back in 1985, have not changed. Indeed, it has been gratifying to go back to the first edition (and the second, and the third) and find nothing significant with which I now disagree. In the main, what I believed about therapy then is what I still believe today, and those ideas still form the core of the book you now hold in your hands. Given that basic similarity, it makes sense to share with you part of the preface of the original edition. It''s about writing a book that . . . tells, as honestly as I can, how to be a psychotherapist. It also tells a lot about me, about the kinds of things that are important to me as a therapist, and the kinds of things that are difficult for me, and the kinds of things that work for me. I hope some of them will work for you too. And I also hope that some of them won''t be right for you, because every therapist needs to build a unique style, taking and rejecting bits and pieces from all sorts of teachers and models. What you decide not to use from these pages will be as important for you as what you decide to keep, for in the very process of deciding you will be shaping your own personal way of doing therapy, your own way of being in the work. There are a few things that may be helpful for you to understand before we actually get started. One has to do with pronouns--the bane of every modem American writer, forced to deal with a language that has no unisex words for her or him, he or she, hers or his. My solution has been to refer to the therapists consistently as "she" or "her" and to the client as "he" or "him." I have two reasons for this choice. First, switching back and forth between masculine and feminine pronouns, in order to balance everything out, is something that I as a reader find distracting. Second, I have frequently been surprised at my own inertial sexist bias, my own unconscious tendency to assume that the "authority" in an ambiguous situation is probably male. If 1, a professional woman, well aware of the issues of sexism in our society, still fall victim to this kind of thinking, then it seems likely that many others do too; referring to the therapist (who is usually regarded as a high-status person) as "she" helps to jolt both myself and you, the reader, into a different level of awareness. Another shortcut I have taken the liberty of using is to omit the words counselorand counselingfrom most of the book, in favor of therapist, therapy,or psychotherapy.Using both ("Counselors and psychotherapists . . ."; "in the counseling or therapy session. . . ") is cumbersome and unwieldy; switching back and forth seems confusing. While a very good case can be made for differences between counseling and psychotherapy, the exact nature of the differences depends on who happens to be arguing about it. Moreover, it is increasingly true that many psychotherapists do a lot of counseling, and that many counselors do a lot of therapy, and that the dividing line between the two is pretty blurred. This is a book about what I would call "therapy"; it''s also a book about what occupies much of the professional life of competent counselors. What I didn''twrite in that first preface, perhaps because I wasn''t as certain about it as I am now, seventeen years later, is that this thing we call either psychotherapy or counseling or both--when it is done properly--is, first and foremost, a matter of relationship. It is the relationship between client and therapist that makes therapy work. The real process of therapy, the real excitement, happens in a kind of in-between that is forged through the therapeutic interaction. It grows out of mutual respect, out of the client''s genuine desire to change and grow and out of the therapist''s regard for the client''s own wisdom. Certainly, the skill of the therapist is another major ingredient. But without a solid therapeutic relationship, skill can do little to help a client. So, as you read about active listening and diagnosis and contract-building and all of the other technical things that therapists do, remember that they all depend on something else, something elusive and hard to put into words: an authentic relationship between two individuals who are willing to be real with each other. Authenticity, being real, is at the heart of the kind of therapy that this book attempts to describe. Because my professional life has taken a number of twists and turns over the last few years (my academic title now has the word "Emerita" tacked onto the end of it), I decided not to tackle a new edition of The Process of Counseling and Therapyon my own. The good folks at Prentice Hall were kind enough to find another professor/author/therapist interested in working with me, and this book is the product of our joint efforts. -- Jan Moursund Although this book has been around for some time, it is this fourth edition that I lend my name to. Simply put: the book needed revisions, and Jan needed help! Over the last year, we have worked together, Jan in Oregon and I in Florida. Thank goodness for e-mail and overnight packages; they have kept this bicoastal project alive. The writing has been an incredible experience for me. It has helped me to define what it is that I do in therapy and to understand why it is so important. I found that I agreed with most of what Jan had to say, which helped make our writing together easier and also validated me as a clinician. I have used this text in my classrooms for years, so I was familiar with its strengths and its weaknesses. When I began to work on the new edition, I used both comments from reviewers and my own ideas. Many of the references in the book have been updated to include the most current work in the field of counseling, but we have not forgotten those "legends" whose words are always timeless. The most obvious addition is the inclusion of a new chapter, "Dealing with Diversity." Given the changing demographics of the United States, it seemed compelling to include such a chapter. Certainly, from my perspective in south Florida, a multicultural society is a reality and not just a scholarly notion. In this new chapter we have tried to provide a sense of how generally to work with individuals who differ from oneself, whether it be in terms of age, ethnicity, or sexual orientation. My thanks go to those who have helped me on my journey to write this book:. my colleague Adriana McEachern, who lent me many sources of information and is a great sounding board; my assistant Salima Patel, who spent endless hours working on the computer and who has suffered through editing each chapter and reference; my "legal mind" in Jim Koenig, handy with legal advice and know-how; my dearest friend Joanna Pera, whose enthusiasm is unsurpassed--she must have been a cheerleader in another life; my partner in practice Irene Marshal--thanks for your support both in practice and friendship